SS–06 Successful Percutaneous Intervention for a Critical Ostial RCA Lesion Using the Distal Anchor Balloon Technique

Abstract

Introduction and Aim: Coronary artery ostial lesions pose significant technical challenges during percutaneous coronary interventions because of inadequate guide catheter support and difficulty advancing devices across the lesion. In such cases, support-enhancing strategies may be employed, including selection of a guide catheter offering stronger backup, the buddy wire technique, deep catheter intubation, use of a guide extension catheter, and the anchor balloon technique. Anchor balloon inflation performed in the distal coronary segment is an effective method that facilitates device delivery by increasing system stability and guide catheter support. In this case report, we present a patient with a critical stenosis at the ostium of the right coronary artery who experienced difficulty with balloon and stent delivery because of insufficient catheter support, in whom a successful percutaneous coronary intervention was performed using the distal anchor balloon technique. Our aim is to highlight the effectiveness of this technique in complex ostial lesions.

Case Report: A 73-year-old woman presented to the emergency department with chest pain. Electrocardiography performed in the emergency department revealed ST-segment elevation in the anterolateral leads, and the patient was taken for coronary angiography (Fig. 1). Imaging of the left coronary system demonstrated total occlusion of the proximal left anterior descending artery (LAD). Two drug-eluting stents were implanted in the LAD, extending from the mid segment to the proximal segment, with successful restoration of flow (Fig. 2). During the same session, critical stenoses were identified in the ostial and mid segments of the right coronary artery (RCA) (Fig. 3), and staged intervention for these lesions was planned. Two days after the initial angiography, the patient was brought back to the catheterization laboratory for the RCA procedure. The RCA was initially engaged with a standard 7F right Judkins guiding catheter. The guidewire was advanced across the lesions; however, when balloon advancement was attempted, the catheter was found to provide insufficient support. Given the anatomical suitability of the RCA take-off, the decision was made to continue the procedure with an internal mammary artery (IMA) guiding catheter, and the catheter was exchanged. The guidewire was re-advanced distal to the lesions. The ostial lesion was first predilated with a 2.5×12 mm PTCA balloon. Subsequently, a 3.5×12 mm non-compliant (NC) balloon was used to redilate both the mid and ostial lesions. It was decided to stent the mid lesion first; however, when stent advancement was attempted, the catheter again failed to provide adequate support. An extra-support wire was therefore advanced distally as a buddy wire. When stent advancement over this wire remained limited by insufficient catheter support, advancement of the stent using the anchor balloon technique was planned. A 3.5×6 mm NC balloon was positioned distally in the RCA as the anchor balloon and inflated at nominal pressure, after which stent advancement was reattempted. With the support provided by the anchor balloon, a 4.0×24 mm drug-eluting stent was successfully advanced to the mid lesion (Fig. 4). Once the stent reached the target site, the anchor balloon was deflated and withdrawn, and the stent was successfully implanted at the mid lesion. The ostial lesion was then redilated with a 3.5×15 mm cutting balloon. Adequate catheter support for the anchor balloon technique was subsequently achieved by entrapping the distal guidewire beneath the previously implanted mid-segment stent, which stabilized the catheter. A 4.0×20 mm drug-eluting stent was then successfully implanted at the ostial lesion, with slight protrusion into the aorta and overlap with the previously placed stent. Postdilation of the overlapping segment of the two stents was performed with a 4.0×20 mm NC balloon. Postdilation within the RCA ostial stent was performed with a 4.5×15 mm NC balloon, and the procedure was completed successfully (Fig. 5). No complications developed during subsequent follow-up, and the patient was discharged on adjusted medical therapy.

Conclusion: Coronary ostial lesions pose serious technical challenges during percutaneous interventions because of inadequate catheter support. In this case, the distal anchor balloon technique successfully facilitated balloon and stent delivery without the need for more invasive alternative strategies. The distal anchor balloon technique should be considered an effective and safe support strategy in complex ostial lesions when standard methods prove insufficient.

Figure and Tables

Figure 1. Patient's initial electrocardiogram at presentation — anterolateral ST-segment elevation.

Figure 2. Total occlusion of the proximal LAD and LAD flow following stent implantation.

Figure 3. Critical ostial and mid-segment lesions on RCA angiography.

Figure 4. Image of stent advancement with distal anchor balloon support.

Figure 5. Final angiographic image of the RCA.